Neurologic and Musculoskeletal Disorders
Summary of the Patient Case Study
The case is about a 43-year-old male patient who walks into a psychiatric clinic aided on a pair of crutches, with the chief complaint of pain in the right lower limb. He has come for a psychiatric assessment after advice from his family doctor who feels the pain may merely be a somatoform disorder and defines it as an “all in his head” incident.
The patient states to have had a fall 7 years ago, landing on his right hip, and after a series of imaging done 4 years ago, was revealed to have a torn cartilage of the right hip joint. His doctors opted for non-surgical interventions and refrained from a complete hip replacement, with the rationale that he is too young for the procedure, and that the tissues will recover spontaneously with time.
Since then, he has had a slew of symptoms, including cold extremities and severe cramping. One of the neurologists diagnosed him with complex regional pain syndrome (CRPS), a diagnosis that his family doctor disputed. The condition interfered with his social and career life, leading to a separation from his fiancée and inability to perform his duties as a machinist. During the interview, he has a two-minute Reynaud phenomenon on his right leg. He has been on Hydrocodone but uses it infrequently due to the adverse effects of sleepiness, constipation, and being loopy.
After a mental state exam which had no concerning findings, I made three decisions to manage the patient. The first decision entails administering Amitriptyline 25 mg PO QHS and titrating upward weekly by 25 mg to a maximum dose of 200 mg per day; the second decision entails increasing Amitriptyline to 125 mg nocte, taking it an hour earlier than usual bedtime, and calling the office to report his function after three days. The third decision was to keep the client’s current Amitriptyline dosage of 125 mg/day and send him to a life coach for advice on healthy eating and exercise habits.
Decision Point One and Evidence-Based Literature
Amitriptyline 25 mg PO QHS and titrate upward weekly by 25 mg to a maximum dose of 200 mg per day
Pain is the most common symptom for which patients with CRPS seek treatment. Although the origin of pain in CRPS is unknown, neurogenic inflammation and alterations in central pain perception are considered to play a role, providing the rationale for the use of drugs with benefits in the therapy of neuropathic pain syndromes, such as Amitriptyline (Shim et al., 2019).
Iolascon and Moretti (2019) state that a typical initial dosage of Amitriptyline (10 or 25 mg nocte) may be utilized, followed by a progressive increase as tolerated. I anticipate attaining a pain scale of 3 from the present 9/10 with the medication, that the client will be able to walk about without the use of crutches, and that the frequency of the Reynaud phenomena will decrease.
Results and Difference in Expectations
After four weeks, he returns to the clinic on crutches, but with a pain score of 6/10, compared to my original anticipation of 3/10, and reports being sleepy in the morning. Furthermore, he adds that he does not always require crutches since he can walk to the restroom and the kitchen without them and that the pain of the right leg and toe curling have subsided significantly. Due to the disparity between the original expectation and what has been achieved, the next therapeutic decision will be initiated.
Decision Two and Evidence-Based Literature
Continue current medication (Amitriptyline) and increase the dose to 125 mg nocte, take it an hour earlier than usual BEDTIME tonight, and call us on the third day to report progress and function.
The Amitriptyline administration guidelines recommend progressively increasing the dose as tolerated. According to Javed and Abdi (2021), when the therapeutic objectives are not met, a progressive increase in the dosage as tolerated greatly reduces pain and improves sleep. Taking the drug one hour before sleep, or earlier in the evening will lessen morning grogginess, and reporting the function on the third day will assess medication adherence.
Results and Difference in Expectations
After four weeks, the patient has a pain score of 4/10 and no complaints of grogginess in the morning. Amitriptyline’s adverse effects include confusion and dizziness (Komoly, 2019), which the patient describes as morning grogginess. He claims that the cramping of the right leg and toe curling only happened twice last month and that he no longer needs crutches to walk, which are both positive remarks.
He does, however, note that he has gained weight, claiming to have gained 3 kgs in the last month. The original goal of pain alleviation to 3/10 is virtually met, as is the hope of walking without crutches and minimizing the frequency of cramping and toe curling.
Decision Point Three and Evidence-Based Literature
Continue the current dose of Amitriptyline 125 mg per day, and refer the client to a life coach to counsel him on healthy dietary and exercise habits.
At this point, the patient is nearly at his goal of pain control and increased functioning, so maintaining the Amitriptyline dose is reasonable. He does, however, gain weight, which would necessitate either a dosage reduction or lifestyle changes such as dietary and physical activity (Gill et al., 2020).
However, reducing Amitriptyline dosage will come at a significant cost to pain control, making lifestyle changes the most logical course of action. A nutritionist, dietician, exercise instructor, or gym expert are just a few of the professionals who may work closely with the patient to help him lose weight.
Results and Difference in Expectations
So far, pain management is almost complete, and the patient’s functioning has improved. He has not had any toe-curling and has only had one incident of cramps in his right leg in the last month. He claims to be feeling well and is considering taking the drug on alternating days.
He is thankful to the healthcare personnel who have been assigned to his care, and a team of three doctors has volunteered to supervise follow-up on him through virtual interaction platforms for the next four weeks, merely to extend the care beyond the hospital’s immediate proximity.
Conclusion
Although it is not commonly diagnosed, CRPS may be suspected in circumstances when the pain is disproportionate in duration or degree to the normal course of known trauma or any lesion. The patient presents with a history of a fall 7 years ago, which may have been the precipitating incident; nonetheless, it is insufficient to explain the current symptoms.
As demonstrated in the patient’s case scenario, pain is the primary symptom for seeking medical attention in the majority of CRPS cases. Clinicians may elect to attempt several courses of pharmacotherapy to aid patients with pain management, with the use of antidepressants such as Amitriptyline, as demonstrated in the case, being one of them.
References
Gill, H., Gill, B., El-Halabi, S., Chen-Li, D., Lipsitz, O., Rosenblat, J. D., Van Rheenen, T. E., Rodrigues, N. B., Mansur, R. B., Majeed, A., Lui, L. M. W., Nasri, F., Lee, Y., & Mcintyre, R. S. (2020). Antidepressant medications and weight change: A narrative review. Obesity (Silver Spring, Md.), 28(11), 2064–2072. https://doi.org/10.1002/oby.22969
Iolascon, G., & Moretti, A. (2019). Pharmacotherapeutic options for complex regional pain syndrome. Expert Opinion on Pharmacotherapy, 20(11), 1377–1386. https://doi.org/10.1080/14656566.2019.1612367
Javed, S., & Abdi, S. (2021). Use of anticonvulsants and antidepressants for treatment of complex regional pain syndrome: a literature review. Pain Management, 11(2), 189–199. https://doi.org/10.2217/pmt-2020-0060
Komoly, S. (2019). Treatment of complex regional pain syndrome with amitriptyline. Clinical Neuroscience, 72(07-08), 279-281. DOI: https://doi.org/10.18071/isz.72.0279
Shim, H., Rose, J., Halle, S., & Shekane, P. (2019). Complex regional pain syndrome: a narrative review for the practising clinician. British Journal of Anaesthesia, 123(2), e424–e433. https://doi.org/10.1016/j.bja.2019.03.030
Neurologic and Musculoskeletal Disorders and Opioids
Write a 1-2 paper that addresses the following:
Briefly summarize the patient case study you were assigned, including the THREE decisions you made for the patient presented.
Based on the decisions you recommended for the patient case study, explain whether you believe the evidence-based literature supported the findings provided. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources.
What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources.
Explain any difference between what you expected to achieve with each of the decisions and the results of the decision in the exercise. Describe whether they were different. Be specific and provide examples.
Case study: Complex Regional Pain Disorder
White Male With Hip Pain
BACKGROUND
This week, a 43-year-old white male presents at the office with a chief complaint of pain. He is assisted in his ambulation with a set of crutches. At the beginning of the clinical interview, the client reports that his family doctor sent him for psychiatric assessment because the doctor felt that the pain was \"all in his head.\" He further says his physician believes he is making stuff up to get \"narcotics to get high.\"
SUBJECTIVE
The client reports that his pain began about seven years ago when he sustained a fall at work. He states that he landed on his right hip. Over the years, he has had numerous diagnostic tests (x-rays, CT scans, and MRIs). He reports that about four years ago, it was discovered that the cartilage surrounding his right hip joint was 75% torn (from the 3 o\'clock to 12 o\'clock position). He reports that none of the surgeons he saw would operate because they felt him too young for a total hip replacement and believed that the tissue would repair with the passage of time. Since then, he reported the development of a strange constellation of symptoms, including cooling of the extremity (measured by electromyogram). He also says that he experiences severe cramping of the extremity. He reports that one of the neurologists diagnosed him with complex regional pain syndrome (CRPS), also known as reflex sympathetic dystrophy (RSD). However, the neurologist referred him back to his family doctor for treatment of this condition. He reports that his family doctor said, \"there is no such thing as RSD; it comes from depression,\" which prompted the referral to psychiatry. He reports that one specialist he saw a few years ago suggested that he use a wheelchair, to which the client states, \"I said \'no,\' there is no need for a wheelchair, I can beat this!\"
The client reports that he used to be a machinist, where he made \"pretty good money.\" He was engaged to be married, but his fiancé got \"sick and tired of putting up with me and my pain; she thought I was just turning into a junkie.\"
He reports that he does get \"down in the dumps\" from time to time when he sees how his life has turned out but emphatically denies depression. He states, \"you can\'t let yourself get depressed... you can drive yourself crazy if you do. I\'m not sure what\'s wrong with me, but I know I can beat it.\"
During the client interview, the client states, \"oh! It\'s happening, let me show you!\" this prompts him to stand with the assistance of the corner of your desk; he pulls off his shoe and shows you his right leg. His leg is turning purple from the knee down, and his foot is clearly in a visible cramp as the toes are curled inward, and his foot looks like it is folding in on itself. \"It will last about a minute or two, and then it will let up,\" he reports. Sure enough, after about two minutes, the color begins to return, and the cramping in the foot/toes appears to be releasing. The client states, \"if there is anything you can do to help me with this pain, I would really appreciate it.\" He does report that his family doctor has been giving him hydrocodone, but he states that he uses it \"sparingly\" because he does not like the side effects of feeling \"sleepy\" and constipation. He also reports that the medication makes him \"loopy\" and doesn\'t really do anything for the pain.
MENTAL STATUS EXAM
The client is alert and oriented to person, place, time, and event. He is dressed appropriately for the weather and time of year. He makes good eye contact. Speech is clear, coherent, goal-directed, and spontaneous. His self-reported mood is euthymic. Affect consistent with self-reported mood and content of the conversation. He denies visual/auditory hallucinations. No overt delusional, or paranoid thought processes are appreciated. Judgment, insight, and reality contact are all intact. He denies suicidal/homicidal ideation and is future-oriented.
Diagnosis: Complex regional pain disorder (reflex sympathetic dystrophy)
Decision Point One: Select what you should do:
Savella 12.5 mg orally once daily on day 1; 12.5 mg BID on days 2 and 3; 25 mg BID on days 4-7; and 50 mg BID after that.
Amitriptyline 25 mg PO QHS and titrate upward weekly by 25 mg to a maximum dose of 200 mg daily.
Neurontin 300 mg PO BEDTIME with weekly increases of 300 mg per day to a max of 2400 mg if needed